Acem 2011 pediatric transport darin

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Acem 2011 pediatric transport darin

  1. 1. Pediatric Transport Darin Aranwutikul, MD.
  2. 2. GoalEarly stabilization and initiation of advanced care at the referring institution, with continuation of critical care therapies and monitoring en route.
  3. 3. Recognition & assessment ofthe sick childPediatric assessment triangle(PAT): A-B-C
  4. 4. Appearance : TICLS MnemonicTone Refers to child’s muscle toneInteractivity Refers to degree of interaction the child has with his/her environment or those attempting to interact with the childConsolability Refers to the child’s response to parents or caregiversLook /gaze Identifies whether the child tracks things appropriately with his/her eyes or has a nonfocused gaze.Speech/cry Refers to how the child vocalizes
  5. 5. Primary assessment A B • Airway • Breathing • Circulation E C • Disability • Exposure D
  6. 6. Airway• Patency• Need simple management  positioning  head tilt-chin lift  Use airway adjuncts ( oral airway)• Require advanced intervention  ET intubation  cricothyroidotomy  CPAP
  7. 7. Breathing • Respiratory rate • Respiratory effort • Airway and lung sounds • Pulse oximetry
  8. 8. Normal respiratory ratesby age Age Breaths per minutesInfant (<1 year) 30 to 60Todler( 1-3 yrs) 24 to 40Preschooler ( 4-5 yrs) 22 to 34School age ( 6-12 yrs) 18 to 30Adolescent ( 13-18 yrs) 12 to 16
  9. 9. Respiratory rate • Apnea • Tachypnea • Bradypnea Bradypnea or irregular respiratory rate in anaccutely ill infant or child often signals impending arrest
  10. 10. Abnormal lung and airway sounds • Stridor upper airway obstruction • Wheezinglower airway obstruction • Grunting lung tissue disease • Crackles  lung tissue disease
  11. 11. Pulse oximetry • Above 94% in room air • Additional intervention is required if O2 sat<90% in child receiving 100% oxygen . • Be careful to interpret pulse oximetry in conjunction with clinical assessment and other signs.
  12. 12. Circulation• Evaluate cardiovascular • Evaluate end-organ function function  heart rate and rhythm  brain perfusion  pulses  skin perfusion  capillary refill time  renal perfusion  blood pressure and pulse pressure
  13. 13. Normal heart rates in children Age Awake rate Mean Sleep rate NB to 3 mo 85-205 140 80-160 3 mo to 2 y 100-190 130 75-160 2 y to 10 y 60-140 80 60-90 >10 y 60-100 75 50-90 Typical physiologic response to a fall in cardiac output is tachycardia.
  14. 14. Blood pressureDefinition of hypotension Age Systolic BP (mmHg) Term neonates <60 Infants <70 Children 1-10 yr 5th BP percentile <70 + (age in years x 2) Children > 10 yr <90
  15. 15. Systemic perfusion• Peripheral Pulses – Present/Absent – Strength• Skin Perfusion – Capillary refill time – Temperature – Color – Mottling
  16. 16. Systemic perfusion• CNS Perfusion – Level of consciousness• Renal Perfusion – Urine 1-2 cc/kg/hr
  17. 17. Disability • Establish the childs level of consciousness • Standard evaluations are  AVPU pediatric response scale  Glasgow Coma Scale (GCS)  pupillary responses
  18. 18. AVPU pediatric response scale
  19. 19. Glasgow Coma Scale(GCS) -
  20. 20. Pupillary response
  21. 21. Exposure• Remove clothing as necessary• Palpate the extremities to assess for injury• Measure core temperature• Keep the child warm• Use spine precautions when suspect spine injury
  22. 22. Life threatening condition Airway • Complete /severe airway obstruction Breathing • Apnea,significant work of breathing, bradypnea Circulation • Absence pulses, poor perfusion, hypotension, bradycardia Disability • Unresponsiveness, depressed conscious • Hypothermia, significant bleeding, Exposure purpura with septic shock, acute abdomen
  23. 23. Secondary assessment• Signs and Symptoms• Allergies• Medications• Past medical history• Last meal• Events leading to presentation
  24. 24. Pediatric assessment flow chart General assessment PAT If any time during the Primary assessment assessment A-B-C-D-E and categorization process You identify a Secondary assessment : life-threatening condition SAMPLE Tertiary assessment Immediately initiate Respiratory Circulatory life-saving interventions and activate theRespiratory distress Compensated shockRespiratory Failure Hypotensive shock emergency response systemRespiratory +circulatory
  25. 25. Breathing is everything to a child• The common denominator for unexpected deaths in children is hypoxia.• Do not increase the childs level of anxiety
  26. 26. Not only the child• Needs of parents or caregivers must be addressed.• Be calm and confident.• Written information and involve them in plan of care.
  27. 27. Children don’t have less pain than adult
  28. 28. Numeric and FACES scale
  29. 29. FLACC scale
  30. 30. Drugs Dose (mg/kg) Route commentsAnalgesicsMorphine 0.1-0.2 ;infusion 20-50 mcg/kg/hr IV Histamine releaseFentanyl 1-2 mcg/kg;infusion 2-5 mcg/kg/hr IV,IO Chest wall rigiditySedativesDiphenhydramine 0.1 IV,POKetamine 1-2 IV,IO,IM Increased ICPlorazepam 0.1-0.2 IV,IO,IM HypotensionMidazolam 0.1-0.2 IV HypotensionPropofol 1-3; infusion 1-3 mg/kg/hr IV HypotensionPentobarbital 2-4 IV Apnea
  31. 31. YOU CANNOT REMEMBERNORMAL WEIGHTS, RESPIRATORYRATES, BLOOD PRESSURES, HEARTRATES, AND CALCULATE DRUG DOSESIN YOUR HEAD SO DONT TRY
  32. 32. Broselow tape
  33. 33. HOW TO STABILIZE THE CHILD
  34. 34. Stabilization of the respiratorysystem • Well oxygenated and ventilating prior to transfer • Consider the need for intubation and mechanical ventilation. • Confirm ETT placement and secure the tube. • Obtain blood gases while ventilating on the transport ventilator before leaving • Consider the need for sedation and paralysis
  35. 35. Stabilization of thecardiovascular system• Hemodynamically stable before departure.• Treat compensated shock before departure.• Invasive arterial blood pressure monitoring in patients with inotropic support.• At least 2 good, working points of IV access.• Ensure availability of emergency or special drugs
  36. 36. Medications to Maintain Cardiac Output and for Postresuscitation Stabilization Medication Dose Range Comment 0.75–1 mg/kg IV/IO over 5Inamrinone minutes; may repeat × 2 Inodilator then 5-10 mcg/kg/minDobutamine 2–20 mcg/kg/min IV/IO Inotrope; vasodilator 2–20 mcg/kg/min IV/IO Inotrope; chronotrope; renal andDopamine splanchnic vasodilator in low doses; pressor in high dosesEpinephrine 0.1–1 mcg/kg/min IV/IO Inotrope; chronotrope; vasodilator in low doses; pressor in higher doses Loading dose: 50 mcg/kg IV/IOMilrinone over 10–60 min Inodilator then 0.25-0.75 mcg/kg/minNorepinephrine 0.1–2 mcg/kg/min VasopressorSodium Initial: 0.5–1 mcg/kg/min; titrate Vasodilator to effect up to 8 mcg/kg/minnitroprusside Prepare only in D5W
  37. 37. Stabilization of the central nervoussystem • Minimize secondary brain injury due to hypotension and hypoxia • Appropriate treatment of prolonged seizures • Adequate sedation
  38. 38. Stabilization of the gastrointestinalsystem • Placement of a nasogastric tube and left on free drainage. • Stop feeding and aspirate the stomach before transfer.
  39. 39. Stabilization of the renal system • Consider urethral catheterisation in children – with shock – who are paralysed and sedated – who have received diuretics or mannitol
  40. 40. Transport team assessment andinitial stabilization • Rapid assessment • Urgent therapy and manage life-threatening conditions is priority • Have patient as stable as possible before loading into the transport vehicle.
  41. 41. EQUIPMENT USED IN PEDIATRICTRANSPORT
  42. 42. General features of allequipment• Self-contained, lightweight and portable• Durable and robust• Long battery life and short recharge time• Clear displays• Suitable for all ages• Visible and audible alarms• Data storage and download capability• Secure
  43. 43. Batteries• Use external sources of power when available.• Choose equipment that is not solely reliant on internal rechargeable batteries.• Do not rely on leaving them charging all the time.
  44. 44. Trolleys
  45. 45. Ventilators
  46. 46. Humidification Heat and moisture exchangers (HMEs):
  47. 47. Temperature maintenance
  48. 48. Infusion pumps • Able to deliver flow rates from 0.1 cc/hr • Able to bolus dose • Should be light, compact and robust • Easy to use • Have alarms • Long battery life
  49. 49. Suction equipment • Portable suction units with battery power • Foot pump suction units
  50. 50. Defibrillators• Portable defibrillator or AED
  51. 51. Monitoring
  52. 52. Others
  53. 53. Reference • American Academy of Pediatrics. Guidelines for Air and Ground Transport of neonatal and pediatric patients, 3rd edition. • David G. Jaimovich . Handbook of Pediatric and Neonatal transport medicine, 2nd edition. • Peter Barry.Paediatric and Neonatal critical care transport, BMJ 2003 • American Academy of Pediatrics. Pediatric Advanced life Support provider manual 2006

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